Healthcare quality problems have long existed in the long term care setting and numerous remedial efforts have been undertaken. One example is Nursing Home Compare (NHC), which in 2002 was the first national policy initiative to provide public access to nursing home quality performance measures. Studies examining quality change in the years immediately following the implementation of NHC have shown modest improvement in the NHC quality indicators.[1, 2] However, research has also shown that quality improvement in response to the NHC policy has not been consistent across facilities and that this variation may be systematic. [1, 3-6] Additionally, there is some evidence to suggest that NHC may affect more than just the quality measures that are publicly reported. [7]Concerns have been raised about whether policies such as NHC that rely on the market to address quality problems will have unintended consequences for vulnerable populations.[8-10] Research has shown that black elders tend to reside in facilities that are heavily reliant on Medicaid, understaffed, and located in poor communities - characteristics that may be associated with weaker motivation or limited capacity to improve quality. [11-14].To date, no studies have explored reasons for heterogeneity in response to NHC, nor have any examined whether differential response to the policy has consequences for black elders. The goal of this dissertation is to explore the effects and consequences of the public reporting of nursing home quality in order to build knowledge about these types of market-based healthcare quality improvement policies. Specifically, the study aims to 1. Determine whether average nursing home quality has improved in response to NHC and whether changes have been sustained;2. Identify key predictors of quality improvement in response to NHC;and 3. Determine whether NHC has had a different impact on nursing homes that serve higher proportions of black elders compared to facilities serving predominantly white residents. Resource Dependency and Institutional Theories will be used to identify patterns of organizational response, as predicted by differing resource constraints, institutional pressures, and interactions therein. To address these research aims, this study will employ an interrupted time series design using data from 1999 through 2007. The study will draw on data from several sources including: Online Survey, Certification, and Reporting (OSCAR), which provides facility characteristics;the Area Resource File (ARF), which contains county level socioeconomic and market data;the Brown University Quality Measures Dataset, which contains nursing home quality measures and facility level characteristics derived from the Minimum Data Set;The Brown University Survey on State Policies, which contains variables related to state Medicaid policies;and Nursing Home Compare dataset, which contains the quality measures reported on the NHC website. Multilevel modeling will be used to address the hierarchical nature of the data. Policymakers can use the findings from this study to help develop effective and equitable healthcare quality improvement initiatives. Findings will help evaluate the long term effects of a policy intended to improve nursing home quality. Results will show how facility, market, and policy factors affect quality improvement and will determine whether the policy has had the same affect on facilities with different racial compositions.